Aamir Bilal

Transthoracic Patent Ductus Arteriosus ligation without chest drain insertion

To study safety of doing Transthoracic, Patent Ductus Arteriosus Ligation without chest tube insertion. Study Design: Observational, Prospective, Descriptive. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from June 2002 to June 2004. Material and methods: This prospective study was done to study the results of this selective approach in forty five (45) patients, operated by transthoracic approach between June 2002 and June 2004 for patent ductus arteriosus ligation. There were 27 females and 18 males, ranging in age from 06 months to 07 years (mean: 2.3 years) and a weight of 6.0 kg to 22.1 kg (mean 11.3 kg). Patients < 07 years, with no pulmonary pathology, no peroperative pulmonary adhesion, no per operative ruptured ductus arteriosus and with good lung expansion prior to the chest closure were included in this study. Patient more than 07 years of age, with extreme adhesion and those whose patent ductus arteriosus ruptured during dissection were excluded from this study. Parents of the patients were informed about potential risks of this selective approach. Only those patients whose parents had given adequate; informed consent were eligible for this study. Results: There was no mortality. No drain related morbidity Iike pneumothorax, haemothorax or chylothorax occurred. P ostoperatively children had less analgesia, earlier feeds and mobilization. Mothers were not apprehensive about holding or feeding the baby. Consequently there was earlier discharge to home. In addition these children had a more cosmetic scar, and no drain related problems. Conclusion: A selective approach to the use of chest tube in Transthoracic approach for patent ductus arteriosus can be safe, cost effective and patient friendly.

Perioperative Pneumoperitoneum after Lobectomy - Bilobectomy operations for Lung Cancer: A prospective study

The aim of this study is to identify the effectiveness of perioperative pneumoperitoneum to prevent air leak after the lobectomy-bilobectomy operations for lung cancer. A prospective study was designed on consecutive 50 patients who had lobectomy-bilobectomy operations for lung cancer and whose remnant lung had failed to fill the half of the hemithoracic cavity under 30 Cm H20 positive pressure ventilation during the operation with totally relaxed diaphragm. The patients were divided into two groups: group 1(25 patients) with perioperative pneumoperitoneum, group 2(25 patients) without perioperative pneumoperitoneum. The statistical analysis between the two groups did not show any significant difference in terms of age, preoperative FEV1, and the type of resection. Perioperative pneumoperitoneum significantly reduced the duration of postoperative air leak (2.2+/-1.15 day versus 6.04+/- 3.16 days<0.0001) and total chest tube drainage time (3.84 +/-0.98 day versus 7.88+/-3.16 days p<0.001). Perioperative pneumoperitoneum after lobectomy-bilobectomy operations for lung cancer is an effective method to decrease air leak and chest tube drainage time.

Collapse therapy in 21st century an experience of 50 cases

Objective: To observe the various indications of thoracoplasty and evaluate their management and outcome. Study Design: An observational descriptive study. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from July 2001 to January 2004. Subjects and Methods: During two and a half years study period fifty patients needed thoracoplasty. M: F ratio was 36:14. Aged distribution was 23 - 57 with a mean age of 36.3 years. Indications for surgery were tubercular or parapenumonic empyema in 25(50%) patients, post lobectomy space infection, and broncho pleural fistula (BPF) in 10(20%), destroyed lung with hemoptysis in 8(16%), post pneumonectomy space infection in 4(8%) and upper lobe hemoptysis with poor PFTs in three (6%) cases. A standard subperiosteal extra pleural paravertebral surgical technique was used in all cases. Out of 50 cases 28 (56%) required full thoracoplasty and 22(44%) cases underwent partial thoracoplasty. Postoperatively all patients had a single chest drain on suction for 7 days. Both the drain and stitches were removed after 2 weeks and patients were advised to attend out patient department for follow-up. Results: Patients symptoms index showed remarkable improvement. 100% improvement was needed in patients regarding chest pain, fever, cough, weight loss, hemoptysis and ATT. Postoperative complications were noted in 10 (20%) cases. Four patients had wound infection, 2 had wound dehiscence, residual space in 3 and restricted shoulder mobility in one. There was 1(2%) mortality. This patient had borderline pulmonary functions and had to be ventilated for ventilatory failure. Conclusion: With the persistent problem of pulmonary tuberculosis in the developing countries, thoracoplasty is still an operation of continued relevance for space obliteration in cachectic patients, and as collapse therapy for bleeding lungs with poor PFTs. Most patients are definitively and rapidly cured with limited sequelae.

Primary chest wall neoplasms - an experience of 39 patients

Objective: To evaluate treatment approaches, role of surgical resection and reconstruction and outcome of patients with primary chest wall tumor. Study Design A prospective observational study. Place and Duration. The study was conducted at the Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from March 1996 to April 2000. Patient and Methods A total of 39 patients underwent resection for primary chest wall tumors. Male were 27 and female were 12. Age range was 15 years - 55 years with a mean age of 23±2 years. 75% of patients presented with a painless mass while 25% complained of pain. Twenty three were on right side, twelve were on the left side while 4 extended onto the sternum. Sizes were 10cm (2 patients). Chest radiograph in all and CT thorax was done in 20 cases. Out of 39 cases, 25 had previous biopsies attempted by other surgeons leading to ulceration and fungation in 18 cases. Chest wall resection and primary closure was done in 33 cases. In 4 cases marlex mesh alone was used while in 2 cases it was reinforced with Methyl Methacrylate. Results Mean operative time was 68 (+/-40) minutes. Postoperatively, 19 patients required ventilation. Out of these, 14 patients were extubated the same day, 3 the next day while 02 patients died despite prolonged ventilation. Post-operative flail was observed in 3 cases without respiratory compromise. Histopathology reporting were chondrosarcoma in 24, fibrosarcoma in 6 cases while the rest were not reported. Twenty one patients were followed-up for up to one year with no evidence of disease while the remaining were lost to follow up. Conclusion To conclude primary chest wall tumors can be safely managed by resection and primary closure or chest wall reconstruction and are associated with long term survival.

Surgery for hemoptysis - one year experience of 72 patients

Objective: To determine aetiology of patients presenting with hemoptysis and evaluate their management and outcome. Study Design: An observational prospective descriptive study. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from 1st Jan 2003 to 31st December 2003. Materials and Methods: This prospective study included 72 patients; 51(71%) were males and 21(29%) were females. Male: female ratio was 2.5:1 Age range was from 7 years to 81 years with a mean age of 36.3 years. All the patients had hemoptysis o n presentation while 25(35%) also experienced dyspnoea. Chest radiograph was obtained in all, CT Thorax in 60 (83%) while pulmonary function tests were performed in 68(94%) patients. Out of 72 cases 09 patients had to undergo immediate surgery, 27 underwent surgery within one week after initial stabilization and 36 were operated upon electively. All patients, except 6 pediatrics cases, had one lung ventilation during surgery. Results: The mean operative time was 55(+/-20) minutes. Out of 72 patients 30 had lobectomy, 24 had hydatid cystectomy, 9 had wedge excision, 3 had pneumonectomy and 6 had thoracoplasty. Mortality was 2/72 while morbidity was 6/72 comprising 4 wound infections (in the emergency group) and 2 each had persistent air leak and empyema. Hospital stay ranged from 7 - 36 days with mean of 12.6 days. Pathological breakup of the 72 cases was bronchiectasis 30, mycetoma 2, lung abscess 9, hydatid cysts 24, carcinoma 6 and AV malformation 1. Conclusion: Inflammatory lung disease, especially TB and its sequelae is the commonest cause of hemoptysis. Elective surgery with one lung ventilation after initial stabilization in a well equipped & well staffed cardiothoracic unit (OT & ICU) is a safe option for hemoptysis, not responding to medical management.

Early surgery for pulmonary Tuberculosis

Objective: The purpose of our study was to analyze current indications for surgery in tuberculosis and evaluate the outcome of early surgical intervention. Place and duration of study: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from June 2000 to July 2004. Material & methods: Total number of cases was 132; M: F 105: 27. Age range was 20 to 79 years. Mean age was 48.4 years. The indications for surgical intervention included 5 cases of pulmonary aspergillioma, 9 cases of pneumothorax; 3 cases of pulmonary nodes and masses without histological diagnosis, 15 cases bronchiectasis, 12 cases of massive hemoptysis and 82 cases of pleural empyema while six patients with multi drug-resistant tuberculosis required surgical intervention. Results: The techniques utilized included lobectomy in 45 cases, pleural drainage in 20 cases, segmented pulmonary resection in 32 cases, surgical procedures on the chest wall in 17 cases, pneumonectomy in 10 cases, decortication in 8 cases. In 22 cases two or more procedures were performed on the same patient. In 26(19.6%) cases various complications were noted of which wound infection was the most frequent. There was a mortality rate of 3.3% (4 cases). Conclusion: Surgical treatment is indicated for the complication of TB and management of MDR TB. Early surgery is beneficial in patients whose disease is still localized and who can tolerate resection surgery; of particular importance is a healthy opposite lung, on which the patient would be dependent during and immediately after surgery.

Esophageal dilatation as palliation for irresectable carcinoma esophagus

Background: The primary therapeutic goals in patients with advanced oesophageal malignancy are the re-introduction of an enteral diet and early discharge. The endoscopic dilation has been proposed as an alternative technique for palliation in patients not suitable for surgery. Aim: To review our experience with oesophageal dilation for the palliation of malignant oesphageal obstruction. Methodology: A retrospective review was conducted of the notes of all patients who underwent palliative oesophageal dilation in our unit. Result: 100 patients (age range 30-90years) underwent oesophageal dilation for malignant oesophageal obstruction 48% of patients had obstruction at lower one third of esophagus. Median survival was 6 weeks (range 1week to 03 months). Successful dilation was possible in 70% of cases. During follow up 20% returned to solid diet, 50% required a soft diet and 30% were unable to tolerate any enteral nutrition. Conclusion: The use of oesophageal dilation achieves, good palliation allowing earl y discharge from hospital, re-introduction of an enteral diet.

Surgical treatment of chest wall tumors (resection and reconstruction) A six years experience

Background: Chest wall resection and reconstruction remains one of the most challenging areas of Thoracic & Plastic Surgery. The purpose of this study is to report our 6-year experience with chest wall resections and reconstructions. Methods: A retrospective review of 36 patients who had chest wall resections from 1998 to 2003 was performed. Result: Patient demographics included tobacco abuse, hypertension, diabetes mellitus, niswar abuse, coronary artery disease, chronic obstructive pulmonary disease, and HCV +ve. Surgical indications included chest wall tumors, and lung cancer involving the chest wall. The mean number of ribs resected was 4±2 ribs. Thirty four patients underwent chest wall resections. Two patients underwent right upper lobectomy along with chest wall resections. Immediate closure was performed in all 36 patients. Primary repair without the use of reconstructive techniques was possible in 9 patients. Synthetic chest wall reconstruction was performed using Prolene mesh, Marlex mesh, methyl methacrylate sandwich, and polytetrafluoroethylene. Flaps utilized for soft tissue coverage were pedicled flaps (2 patients). Mean postoperative length of stay was 14±12 days. Mean intensive care unit stay was 5+4 days. In-hospital and 30-day survival was 100%. Conclusions: Chest wall resection with reconstruction can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.